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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> k <br /> APPLICATION' ` <br /> (I on-Transferable,Revocable,and Suspendablit <br /> . SEPTAGE <br /> ENVIRO_ MENTAL HEALTH PERMIT <br /> N <br /> LIQUID WASTE y <br /> Application is hereby made to carry on business in the jurisdictional area of the Sa0paquin-Local Health District <br /> r 4. Fu L a I- /� Address_ J. 1Ti 15/�1 /y1%o-"o, 1 <br /> q Business Name (DBA) <br /> Owner12 — Address <br /> Firm Partners, Addresses and TelephcGne'rNumbers .` <br /> a. Business Telephone No. 9-'•� �� �1`, Emergency Telephone No. <br /> Contractor Licence No; / . <br /> Applicants Name (Prinf) , ,G'� •ns Title / '' Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information V➢A <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION'AFOR EACH,VEHICLE) <br /> For July 1. June 30, 19 .' _ Disposal Sites 410J <br /> Description(Make/Yr., Color) ',f ` r <br /> Serial No. 1 CAL. License No. _ CAL. License Renewal No. <br /> Capacity -'' Gal.,Weights & Measures No. ' <br /> Equipment Parking Address •`' ' <br /> 2. ❑ PUMPER YARD • " <br /> For July 11 'June 30, 19 " <br /> No. of Vehicles Stored s <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name'• '^ '`' R.S. or R.C.E. No. . <br /> Test Location _ Test,Date/Time " <br /> 4. ❑ SANITATION PERMIT t ,. X_ <br /> Job Address/Location " 7� /JnST,[v- a - <br /> Owner ,!� — 1 ,,,�hI-�a�G Address <%J �C —I <br /> 0 SEPTIC TANK ' ❑ CESSPOOL ' M<EACHING FIELD• �E PIT ❑ PACKAGE PLANT ^� <br /> ❑ PERMANENT ❑ TEMPORARY P NEW EPAIR ` ❑ OTHER4 <br /> 5.,❑ CHEMICAL TOILETS ,For July 1, June.30;19 <br /> Type Construction ` - ` z ` • Pisposal Site <br /> Norof Units Equipment Storage/Cleaning Location(s) <br /> 6x13"-PACKAGE TREATMENT PLANT For July 1, -;June 30, 19 <br /> Operator Name % ,'` Where Certified <br /> Y' <br /> Plant Location - <br /> Plant Capacity - No. Units Served - <br /> 7. ❑ LAUNDRY For July 1',sJune 30; 19 <br /> SIZE: 11 Less Than 1,000 Sq.-Ft., ❑ -More Than'.1,000 Sq. Ft. <br /> 1:1DRY CLEANING,CKemicals'Used/Amount/Mo. ` <br /> I hereby certify'fhat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and r gut ons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX _.v' <br /> FOR DEPARTMENT USE,ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑f PER UNIT ❑ PER SITE:." ❑ EACH': ❑;January 1 d Received By January 31 ❑ July 1 It Received By July 31 <br /> BILUNG REMITTANCE 'S REMIT <br /> BASE ' EXPLANATION AMOUNT DUE CHECKED <br /> 1 DATE I DATE REMITTED AMOUNT <br /> d <br /> 00 <br /> FEE 7 <br /> LESS <br /> PRORATION v <br /> PLUS <br /> PENALTY S'- <br /> 4 - <br /> OTHER <br /> OTHER 1 <br /> o �a� l /aliUlh� � na� <br /> Received by Date - ReWtPI No. Permit No. Iss ante a e Mailed Oe here 0{J <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Bolt 2009 STOCKTON,CA 95201 <br />